WHEN TO START AN ALZHEIMER’S DRUG

How low a diagnostic threshold should one have for prescribing drugs for Alzheimer’s disease (AD)? Is it appropriate to prescribe a trial course for a concerned patient if you believe she has benign senescent forgetfulness rather than early AD?
—Melissa Raue, PA-C, Pound Ridge, N.Y.

Not all forgetfulness is a result of AD, so it is imperative to rule out treatable causes of dementia before embarking on drug therapy that is expensive, minimally effective, and not devoid of serious side effects. Have hypothyroidism and B-vitamin deficiencies been ruled out? Cerebrovascular disease evaluated and treated? Have you considered depression? Medication side effects?

Even if all investigations lead to the conclusion that a patient has AD, drug treatment may be less important than coordinating care and planning for eventual functional decline. Despite advertisements by drug companies, many clinicians believe that treating AD with medication is akin to rearranging deck chairs on the Titanic. Studies seem to support this view. The AD2000 study, the only nonpharmaceutical industry-sponsored trial of cholinesterase inhibitors, found no significant benefit of donepezil compared with placebo for the two primary end points, entry to institutional care and progression of disability. For more information, see Lancet. 2004;363:2105-2115 and Cochrane Database Syst Rev. 2003;(3):CD001190.
—Reuben W. Zimmerman, PA-C (102-7)

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